effect of lowering the reading level of a health education pamphlet on increasing

Effect of Lowering the Reading Levelof a Health Education Pamphleton Increasing Comprehension by ESL Adults

James H. BellReta E. Johnson

Does lowering the reading level of ahealth education pamphlet actuallyincrease the comprehension by adultreaders for whom English is a secondlanguage? We lowered the readinglevel of a general pharmacy educationhandout by changing vocabulary, sentence structure, and organization; byhighlighting the main idea of eachpoint; and by writing an introductiondesigned to catch attention and focusreading. Low-intermediate and advanced English as a Second Language(ESL) college students read either theunaltered (24 students) or altered (25students) version of the pamphlet,which were estimated to be at the grade

12 and grade 7 level respectively according to the Flesch-Kincaid readabilityformula. Subjects then answered a freewritten test and a short-answer test.There was no statistically significantdifference in the reading comprehension scores of the two groups on thefree written test (p=0.14) or on theshort-answer test (p=0.59). Healtheducators and ESL professionals shouldbe wary of using readability formulas toestimate the suitability of materials forESL readers, and of assuming thatlowering the reading level of materialsmeans increasing comprehension evenwhen some changes beyond the lexicaland syntactical are made.

One of the most important kinds of materials that English as aSecond Language adults encounter is general health educationmaterial. Not understanding can be dangerous; misunderstandingcan be just as bad. Health educators are becoming aware that muchmaterial is too difficult for many L2 readers. Often health professionals turn to ESL professionals for help with "lowering thereadability level" of materials. The level is typically calculated withthe assumption that lowering the readability level will increasecomprehension. This assumption is not as common-sensical as itmight first appear. We tested it in an experiment involving adultESL students at an urban, Canadian college.

REVIEW OF THE LI1ERATURE

This study stems from concerns about, and research on,readability in health education and in English as a SecondLanguage.

TESL CANADA JOURNAL/REVUE TESL DU CANADAVOL. 10, NO.1, FALL 1992 9

Readability and Health Education

Health education materials are often too difficult for manyreaders to comprehend. By comparing the readability levels ofmaterials analyzed by readability formulas with the estimatedaverage reading level of adults (grades 8-9), it becomes clear that"much patient education material is potentially incomprehensible toa large portion of the adult population" (Vivian & Robertson,1980). Spadero (1983) found that of the 55 health brochuresreviewed, only 14 (25.5%) were written at or below the grade ninelevel. LaPierre and Mallet (1987) found the average reading levelof 190 Canadian and American health education pamphlets to begrade 11.8±1.7.

Rather than estimating the average adult reading level to begrade 8-9, some studies actually measure the reading level of thetarget audiences for their health education materials. Doak andDoak found that the mean reading level of their subjects wasapproximately grade 7 as estimated by the Wide Range AchievementTest, but that the mean reading level of 100 samples of patienteducation material was approximately grade 10 (Doak, Doak, &Root, 1985). Davis, Crouch, Wills, Miller, and Abdehou (1990)found that most health education materials they examined "requiredaverage reading comprehension grade levels of 11th to 14th" grade(p. 535), while the 151 patients averaged 6th grade 5th month onthe reading sections of the Peabody Individual Achievement Test.

Because of the wide discrepancy between the reading ability ofthe citizenship and the readability levels of the health educationmaterials, writers recommend lowering the readability grade level ofmaterials to less than grade 9 (Spadero, 1983), 8-9 (Lange, 1988), 8or less (LaPierre & Mallet, 1987), less that 8 (Farell-Miller &Gentry, 1989), 7 (Davis et ai., 1990), or 6.5-8.5 (Matthews, Thornton& McLean, 1985). It is assumed that lowering the readability levelof the text will increase comprehension by the readers.

A decade ago, advice emphasized relying heavily on readabilityformulas. For example, Vivian and Robertson (1980) wrote:"Producers of patient education materials should apply readabilityformulas to ascertain the comprehensibility of the offered material"(p. 135). Vivian and Robertson advise shorter words and sentencesfor increased comprehension.

But because readability formulas usually rely on estimates of onlytwo variables-word difficulty and sentence difficulty-patienteducation experts now advise considering other variables affectingcomprehension: the reader, content, organization, and format.

10 JAMES H. BELLIRETA E. JOHNSON

They advise, for example, stimulating the reader's interest (Lange,1988), defining semi-technical terms (Gibbs, Gibbs, & Henrich,1987), ensuring an introduction, body, and summary (Lohr, Ventura,Crosby, Burch, & Todd, 1989), as well as making the changesnecessary to lower the readability level as measured by the formulas.However, the literature does not address a key question: Is therelationship between simplification and comprehension incrementalor all-or-nothing? Is it true that the more readability tipsimplemented in writing a text the more comprehensible the textbecomes? Or must nearly all readability advice be followed toengender significantly improved comprehension? Nor does theliterature seriously question the assumption that lowering thereadability level of health education materials to about the grade 7level as measured by readability formulas will increase comprehension significantly.

Readability and Formulas

While the literature on health education now recommends morethan simplifying vocabulary and shortening sentences, the readabilityformula score is still the imprimatur. This may place unwarrantedconfidence in readability formulas. A readability formula is "apredictive device intended to provide quantitative, objectiveestimates of reading difficulty" (Klare, 1984, p. 684). All rely onestimates of word and sentence difficulty. The Flesch-Kincaid, forexample, uses average sentence length and word length, as thefollowing simplified version of the formula shows:Grade Level = .4(words/sentence) + 12(syllables/word) 16(Klare, 1984, p. 693).Klare reminds us that such formulas are designed to predictreadability, not to produce it. In developing readability formulas,researchers establish a correlation between reader comprehension(usually measured by doze tests) of different passages and someelements of the passages. Estimates of word and sentence difficultyin passages give the highest convenient and reliable correlation withcomprehension. This research does not claim that the relationshipis causal. It is worth noting that while such formulas predictreadability, they do not measure readability. While formulas orexpertise applied to a text yield predictions of readability, tests ofreader comprehension measure readability.

Of the most common readability formulas, the Flesch seems wellsuited to our research. The Spache formula is designed for veryelementary materials (grades 1-3). The Dale-Chall is based on a


dated list of common words (Dale & Chall, 1948). The Raygoryields essentially the same results as the Fry, counting letters inwords rather than syllables (Baldwin & Kaufman, in Klare, 1984).Although the raw scores from the Fry, Flesch, and SMOG formulascorrelate highly, when these scores are converted to grade equivalents, SMOG yields grade levels higher than other formulas(Spadero, 1983) and Fry yields scores lower than average (Guidry &Knight, 1976). According to Klare, author of the readability chapterin Handbook of Reading Research (1984), the Flesch is the mostwidely used, and "more computer programs have been developed toapply [it] than any other formula" (p. 690).

Even used properly, readability formulas have many weaknesses.Formulas have high correlations with passage difficulty when theyare tested with a wide range of readers on a large number of texts ofvarying content and difficulty. But in normal application, formulasare often used for a narrow range of reading ability and a smallnumber of passages on a particular subject and with a restrictedrange of difficulty. This use is legitimate, but the predictive powerof the formulas decreases. It is also well to remember that thepredictive power of formulas was generally developed with schoolpupils and the extrapolation to adults, speakers of English as asecond language, and especially ESL adults must be viewedcritically.

Yet readability formulas will continue to be used widely becausealternatives are not promising. Testing-that is, actually measuringreadability-is time consuming, requiring creating valid and reliabletests, administering them to appropriate subjects under suitableconditions, and calculating and interpreting results. Judging, acommon method, is risky for non-experts. Even people who areusually considered to be good judges of readability may not be.Klare (1984) cites research showing school and pUblic librariansrating one book from grade 3 to grade 12 in difficulty, professionalwriters rating five passages at all but one of the five possible levelsof difficulty, and teachers' judgements varying by six to nine gradelevels. Individuals who are not specially trained are not reliablejudges of readability.

Readability and ESL

Although readability formulas are less commonly used in the ESLfield than the health education field, readability in ESL often has asimilar focus: vocabulary size and the difficulty of grammaticalstructures (Hetherington, 1985). Numerous authorities argue


eloquently for including considerion of content, discourse features,format, and, most importantly, the reader, as well as linguisticvariables (Carrell, 1987; Hetherington, 1985; LotheringtonWoloszyn, 1988). The research is sparse and inconclusive, but itcalls into question focusing heavily on the lexical and syntactical.

Johnson's (1981) study indicated by multivariate analysis ofvariance that "the level of syntactic and semantic complexity [of anEnglish language text] had a lesser effect than did the cultural originof the text on the reading comprehension" (p. 171) of 46 Iranianintermediate/advanced ESL students at an American university.Nonetheless, the Iranian students understood the simplified versionof an American folk story better than the unaltered original.

Blau (1982) developed three versions of 18 paragraphs, eachversion differing in the degree of sentence combining. Analysis ofcovariance indicated no significant difference in comprehension for85 Puerto Rican ESL college students among version 1 (primarilysimple sentences), version 2 (complex sentences with surface cluesto relationships), and version 3 (complex sentences with sophisticated, subtle clues to relationships). Post hoc, says Blau, one couldreason as follows: If one were to use readability levels as a guide informulating a directional research hypothesis, a logical statementwould be that comprehension of version 1 will be superior tocomprehension of version 2, a one-tailed t-test. This hypothesiswould not be supported (p <0.45).

Floyd and Carrell (1987) were able to achieve more definiteresults by making the variables extreme. Twenty intermediate-levelESL students were divided into an experimental group whichexperienced two carefUlly planned, dynamic lessons on IndependenceDay in Boston, and a control group which did its normal schoolwork. Both groups read a letter about the Fourth of Julycelebrations in Boston, half the students reading an unaltered text(average T-unit length = 11.34) and half reading a syntactically lesscomplex text (average T-unit 8.67 words). As measured by anobjective test and a free written recall test, teaching the culturalbackground facilitated reading comprehension, but differences insyntactical complexity showed no significant difference incomprehension.

Brown (1985) tested intermediate ESL students (mean readinggrade level = 5.6) on three versions of a text: (1) the originalversion (grade 10 level); (2) a modified input version wheresentence structure and vocabulary were simplified (grade 5 level);and a modified interaction version where repetition, definition, andclarification were used in an effort to enhance comprehension


(grade 9 level). The 30 ESL students scored as follows on the 20question multiple-choice test: (1) 8.6 correct, (2) 14.3, and (3) 13.5.Although the differences are not statistically significant, they suggestthe power of modified interaction to help ESL students comprehendmaterial which formulas predict is too difficult.

Strother and Ulijn (1987) altered 10 sentences in a general articleabout computers. They syntactically simplified three structuresfrequent in the science and technology register: passives, nominalizations, and participles. They gave the two versions of the articleto three groups: L1 computer and humanities students, ESL Dutchand Chinese computer students, and a variety of ESL students notenrolled in computer courses. Participants answered 10 true/falsequestions directly related to the 10 altered sentences. Strother andUlijn found "no significant differences among various groups,whether controlling for language background, backgroundknowledge of the subject to be tested, or the register of the textitself" (p. 97). Although this study has several significant flaws, it isuseful in pOinting out the difficulty of detecting comprehensiondifferences when only minor grammatical changes are made to atext.

These studies cast doubt on the significance of lexical andsyntactical simplification, and they show the difficulty of detectingchange when only minor variables are manipulated. Klare (1984)has identified 156 distinct readability variables. Rather than tryingto test them one at a time, it may be advisable to test several atonce. We made several kinds of textual changes in "simplifying" thehealth education material used in testing the following nullhypothesis: There is no difference in comprehension between adultESL students who read a "simplified" version of a general pharmacyeducation pamphlet and those who read a more difficult version.

METHOD

Design

This experimental study was a posttest-only control group design.Students at the advanced level and students at the low-intermediatelevel were randomly assigned at each level to groups, one receivingversion A (unaltered) of the pamphlet (24 subjects), the otherversion B (altered) of the pamphlet (25 subjects). After reading thepamphlets, all students wrote the same comprehension tests.


Pamphlets and Tests

Version A of the pamphlet was written by a hospital clinicalpharmacist as general information on how to take medication safelyand effectively. The readability level was grade 12 as calculated bythe Flesch-Kincaid as incorporated in the computer softwareGrammatik IV.

In revising version A, we did not lIwrite to formula," making onlythose word and sentence length changes which would lower thereadability score. We did not identity and eliminate three-syllablewords. We did not analyze complex sentences and then turn theminto simple sentences. Rather, as health professionals might do, andas many plain language consultants do, we aimed to write natural,considerate prose rather than calculated, simple prose. But then, ashealth professionals would do, we checked the readability level.After four revision cycles, we obtained a readability score of grade 7and, as recommended in the health education literature, stoppedrevising. For the types of changes made and not made, see Table 1.For excerpts from versions A and B, see Appendix A. The contentin versions A and B was judged to be essentially the same by fourhospital pharmacist, two with more than 15 years' experience andtwo with 3 years' experience. The teachers of the low-intermediateclasses judged version B as understandable by their classes, and theteachers of the advanced classes judged version A comprehensible totheir students.

TABLE 1

Types of Changes Made and Not Made to Version A

Changes made

Sentencesa) shortenedb) simplified structure, especially active instead of passive construction, and fewersubordinate clausesc) made less abstract (e.g., direct form of address: "you")

Vocabularya) used fewer lengthy wordsb) used fewer technical wordsc) used fewer difficult wordsd) defined key terms


Introductiona) provided a more interesting, concrete titleb) caught attention with the opening sentencec) gave a specific purpose or purposes for reading

Organizationa) organized points by chronology and importanceb) organized individual points to emphasize main ideas through topic sentencesplaced first

Formatprovided short, bold imperatives for each point

Some changes not made

Sentencesnot reduced to one idea per sentence

Organizationno obvious indication of the organizational framework

Contentnot changed significantly

Lengthnot altered significantly

Formata) spacing not changedb) not all upper and lower case lettersc) type not large (e.g., 12 or 14 point)d) graphics not added

Discourse genre or typenot changed from a list

In light of what the patient education pamphlet tried to achieve,two reading comprehension tests were constructed. Pharmacistswant patients going home to remember the content of the pamphletand then use what they have learned about taking their medicationsafely. To approximate the emphasis on remembering, we gaveparticipants a free written test asking them to list 10 of the 12points in the pamphlet. But patients' home environments may helpthem recall advice they have forgotten. For example, going to takemedicine in the dark may remind them of the prohibition againstdoing so. Thus we gave participants a short-answer test which askedthem to fill in the blanks on times requiring recall of details and on


items requiring application of information from the pamphlet. SeeAppendix B for excerpts from the tests.

Subjects

The 49 subjects were adult students in an academic preparationESL program at a Canadian community college. The advanced levelwas the last of seven levels before mainstream college courses. Bothadvanced classes volunteered for the study. The low-intermediatelevel was the third of the seven levels. Two of the three classesvolunteered. The instructor of the third class refused to participatebecause she felt that she could not afford to relinquish the two classperiods required for the study. Twelve of the potential 61 subjectsdid not complete the study: 10 were absent from the first or secondsession, 1 refused to finish the tests, and 1 moved to a class notinvolved in the study.

As a demographic questionnaire showed, the subjects were avaried group. They spoke a wide variety of first languages, withonly Spanish (13 subjects) and Cantonese (11) forming noticeablegroups. Ages ranged from 18 to 48, the mean being 24. Evaluationof the demographic data using boxplots and exploratory dataanalysis showed no important differences between the group whichread the altered pamphlet and the group which read the unaltered.Neither were CAAT reading scores significantly different (differencein means = 4.78; 95% confidence interval for difference in means =(-7.5, 1.1); P = 0.14). This indicates that randomization techniqueswere effective.

Procedure

We pilot tested procedures and tests with an intermediate-levelESL class at the college. This helped us clarify instructions, revisetest questions, and determine a maximum reading time of eightminutes.

One researcher (JB) conducted all of the classroom sessions in aneffort to ensure consistency and to provide a check that the subjectswere taking the tasks seriously. First, all subjects were tested withthe reading comprehension section of the appropriate level of theCanadian Adult Achievement Test (CAAT). This test is up-tO-date,designed for adults, and emphasizes functional reading skills. Allstudents completed a questionnaire designed to collect demographicinformation. Subsequently, students were given their CAAT resultsand reading profiles, and told how to interpret the results.


In the second session, students read version A or B of thepamphlet and answered questions on what they had read. Toincrease motivation, students were told that during the session theywould learn important knowledge about taking medication safelyand effectively, that they would help a hospital design a pamphletsuitable for its many ESL clients, and that they would be taught amemory technique to improve reading comprehension. Studentswere then instructed to read the pamphlet at their average readingspeed and to try to remember the contents. They were asked not tostudy or attempt to memorize it. When finished, the students notedthe time taken, according to times written on a blackboard at 30second intervals.

SUbjects then completed a freely written recall test (Part I) whichasked them to list 10 or the 12 points in the pamphlet. Afterhanding these in, they were given 15 fill-in-the-blank questions (PartII). To finish the session, students were taught a short lesson onremembering lists by associating list items with images.

The Tests were marked independently by the researchers. On anytest where scores differed by more than one point, the differencewas resolved through discussion. Part I and Part II scores wereaveraged separately.

Data were analyzed using the Minitab statistical paCkage for IBMcomputers. Demographic data were compared using the KruskalWallis test for ranked data. Chi-square tests and exploratory dataanalysis were used for categorical data. Mean CAAT scores, time,and comprehension test scores were analyzed using Student's t-test.The a priori level of significance was set at 0.05.

Results

We found no statistically significant differences between thecomprehension test scores of the group reading the unalteredversion and the group reading the altered version of the pamphlet(See Table 2). There was no statistically significant differencebetween the groups' scores on the free written test or on the shortanswer test. Subjects finished the unaltered pamphlet in a meantime of 5.12 minutes, the altered version in 5.34 minutes. Thedifference in reading time was not statistically significant [meandifference = 0.22; CI = (-0.66, 1.09); p = 0.62].


TABLE 2

Results of Comprehension Tests

Mean Mean Confidence pTests Difference Interval Value

Part IUnaltered text group 6.03 0.04 -0.94, 0.80

1.22

Altered text group 6.17

Part IIUnaltered text group 11.30 0.52 -2.48, 0.59

1.42Altered text group 10.77

Because of low-intermediate students who were particularly goodreaders and advanced students who were unusually weak readers, thecombined comprehension test scores (Part I + Part II) ranged fairlyevenly from 9 to 26 out of a possible 29 correct. This range,however, raises an important consideration: perhaps no significantdifference was detected between the groups reading version A and Bbecause the advanced readers, who could comprehend both difficultand easy versions, washed out a significant difference between lowintermediate students who read version A and those who readversion B. To investigate this possibility, we looked at the twolevels separately. Although the size of each group becomes toosmall to allow conclusions with confidence, there seems to be nosignificant difference between advanced students' comprehension ofversions A and B (as might be expected), but neither does thereseem to be a significant difference among low-intermediate students'comprehension of versions A and B (See Table 3). These smallergroups did not differ significantly on demographics, reading scoresor pamphlet reading time.


TABLE 3

Results of Comprebension Tests by Level

TestsMean Mean

DifferenceConfidence

Intervalp

Value

Low-Intermediate Level

Part I (total score=10)Group A (Unaltered) 5.35

Group B (Altered) 4.81

Part II (total score=19)Group A (Unaltered) 9.70


Part I (total score=10)Group A (Unaltered) 6.89


Part II (total score=19)Group A Unaltered) 12.71


Discussion

0.54

0.79

Advanced Level

0.13

0.02

-1.86,0.78

-3.86,1.21

-1.50,1.56

-2.33,2.28

0.40

0.28

0.86

0.98

Why did lowering the readability level of the health educationmaterials from grade 12 to grade 7 levels make no significantdifference in comprehension for the ESL readers?

Although it is possible that the sample size of 49 was too smallto detect a difference, the mean scores of the experimental andcontrol groups were so close that it is doubtful that a larger samplesize would have revealed a significant difference.

The motivation of the students to remember the informationcontained in the pamphlet might also be questioned. However, only


one of the students refused to complete the task, and the personadministering the tests noted that the students seemed to take thetask seriously. It is tempting to compare the students' motivation inreading general interest health education material with the patients'motivation, and to see the patient as highly motivated because he orshe has been prescribed medication. However, the patient may notread the information at all. Or the patient might be so anxious thatcomprehension is hindered. Therefore, the difference in motivationbetween patients and keen academic students may not be as great asmight be assumed.

Besides motivation, background knowledge is probably the majorvariable in comprehension (Klare, 1984). Thus cultural backgroundmay have made comprehension difficult. The only way in which thestudy addressed this was to have subjects from a wide variety ofcultures.

A major factor affecting comprehension was the difficulty ofremembering a list of 10 points. This is especially true becausesubjects were instructed to read, not study, the pamphlet. Furthermore, the items are not clearly inter-related, so remembering oneitem does not necessarily bring to mind another item. Although theitems were re-arranged into a somewhat chronological order inversion B, this may have been too subtle for students to detect andto use as a memory aid.

Perhaps the grade 7 reading level of the altered pamphlet was noteasy enough for low-intermediate readers. Although both lowintermediate instructors thought their students could comprehendthe pamphlet, one teacher pointed out elements which studentsmight find difficult. Some vocabulary was fairly advanced:swallowing, procedure, label, effect, transfer, original, harmful, andguide. Speakers of Romance languages, such as the 13 Spanishspeakers in this study, might use their knowledge of Latin-basedwords to understand procedure, effect, transfer, and original; butsubjects such as the 11 Cantonese speakers would have no suchhelp. However, all of the above words identified as difficult weredefined by their context. In addition to vocabulary, some sentencesand expressions were fairly difficult for low-intermediate students.Consider this sentence from the point encouraging readers to asktheir pharmacist for additional information about their medication:"This information and advice from your pharmacist is part of thecost of your medication." Although this is a simple sentence withvocabulary the readers know, it is rather abstract. "Your pharmacistwill give you this information free" is not quite accurate factually,but it more concrete and easier to understand and remember.


There may not have been enough difference between the twoversions of the pamphlet. We made three substantial changesbeyond lexical and syntactical: we included an introduction designedto stimulate interest and guide reading; we reorganized individualpoints and highlighted the topic sentence of each; and wereorganized the order of the points. But we did not make some ofthe other commonly recommended changes. We did not addgraphics and enlarge the type and leave more white space for aninviting design, easy on the eye. We did not make the organizationexplicit, say, by using large headings. Nor did we simplify thevocabulary and sentence structure as much as we might have. Andthe lengthy, twelve-point list remained intact. Consequently, thepamphlets may not have been altered enough to produce asignificant difference in comprehension.

To assume that lowering the readability level-even as much asfive grade levels-results in improved comprehension for adult ESLreaders is risky. That assumption is suspect even when somechanges beyond the lexical and syntactical are made. This suggestsmaking nearly all of the commonly recommended readabilitychanges when simplifying a text. The assumption is that so radicallyaltering a document will result in improved comprehension, but, ofcourse, this should be tested.

ACKNOWLEDGEMENTS

1. This study was supported by a grant from the Research andDevelopment Committee, calgary General Hospital.2. We gratefully acknowledge the help of D. George, D. Goring, J.Goring, P. Pankratz, R. Raughton, A. Trussler, D. Van Staalduine,D. Warkentin, D. Wood, H. Holley for her assistance with thestatistical analysis, and the Department of PSYChiatry, calgaryGeneral Hospital, for access to computers and statistical software.

THEAUITIORS

James Bell (Ph.D., University of Texas) is director of the calgaryAdult Literacy Awareness Project. He is particularly interested inteaching written composition.

Reta Johnson (Pharm.D., University of Texas) is Manager, Clinical,Research and Education at The calgary General Hospital. She isparticularly interested in pharmacy care plans.


REFERENCES

Blau, E. K. (1982). The effect of syntax on readability for ESLstudents in Puerto Rico. TESOL Quarterly, 16(4),517-527.

Brown, R L. (1985). A comparison of the comprehensibility ofmodified and unmodified ESL reading materials. Unpublishedmaster's thesis, University of Hawaii, Honolulu, HI.

Carrell, P. L. (1987). Readability in ESL. Reading in a ForeignLanguage, 4(1),21-40.

Dale, E. & Chall, J. S. (1948). A formula for predicting readability.Educational Research Bulletin, 27, 11-20, 37-54.

Davis, T. c., Crouch, M. A., Wills, G., Miller, S., & Abdehou, D. M.(1990). The gap between patient reading comprehension and thereadability of patient eduction materials. The Journal of FamilyPractice, 31 (5), 533-538.

Doak, C. c., Doak, L. G., & Root, J. H. (1985). Teaching patientswith low literacy skills. New York: J. B. Lippincott.

Farrell-Miller, P. & Gentry, P. (1989). How effective are yourpatient education materials? Guidelines for developing andevaluating written educational materials. The Diabetes Educator,15(5),418-422.

Floyd, P. & Carrell, P. L. (1987). Effects on ESL reading ofteaching cultural content schemata. Language Learning, 37(1),89-108.

Gibbs, R D., Gibbs, P. H. & Henrich, J. (1987). Patient understanding of commonly used medical vocabulary. The Journal ofFamily Practice, 25(2), 176-178.

Guidry, L. J. & Knight, D. F. (1976). Comparative readability:Four formulas and Newberry books. Journal of Reading, 19, 552556.

Hetherington, A. (1985). Assessing the suitability of readingmaterials for ESL students. TESL Canada Journal, 3(1), 37-51.

Johnson, P. (1981). Effects on reading comprehension of languagecomplexity and cultural background of a text. TESOL Quarterly,15(2), 169-181.

Klare, G. R (1984). Readability. In P. D. Pearson (Ed.),Handbook Of reading research, (pp. 681-744). New York:Longman.

Lange, J. W. (1988). Developing printed materials for patienteducation. Dimensions of Critical Care Nursing, 8(4), 250-258.

Lohr, G., Ventura, M. R, Crosby, F. , Burch, K., & Todd, K(1989). An experience in designing patient education materials.Journal of Nursing Staff Development, 5(5), 218-224.


LaPierre, G. & Mallet, L. (1987). Readability of materials.Canadian Pharmaceutical Journal, 120, 718-728.

Lotherington-Woloszyn, H. (1988). On simplified and simplifyingmaterials for ESL reading. TESL Talk, 18(1), 112-122.

Matthews, P. J., Thornton, L., & McLean, L. (1985, July). The useof readability fomlUlas in patient education materials. Paperpresented at the American Association for Respiratory TherapySummer Forum, Reno, NV.

Spadero, D. C. (1983). Assessing readability of patient informationmaterials. Pediatric Nursing, 9, 274-278.

Strother, J. B. & Ulijn, J. M. (1987). Does syntactic rewritingaffect English for science and technology (EST) text comprehension? In J. Devine, P. L. Carrell & D. E. Eskey (Eds.), Researchin reading in English as a second language (pp. 89-110).Alexandria, VA: Teachers of English to Speakers of OtherLanguages.

Vivian, A. S. & Robertson, E. J. (1980). Readability of patienteducation materials. Clinical Therapeutics, 3(2), 129-136.


APPENDIX A

Sample Points from the Health Education Pamphlets

Version A: Medication guide for the home patient1. When your physician prescribes medication for you, be sure totake it. Is is a waste of time and money if you visit your doctor foradvice and then do not follow it.2. It is essential to follow the instruction for taking your medication.The dosage time interval between doses, and the duration of yourprescription therapy were carefully specified by your physician andare all essential to the success of your treatment. Follow theinstructions exactly, for too Iowa dosage can be just as dangerous astaking too much.3. In order to avoid taking the wrong medication, follow a practiceused by pharmacists to avoid mistakes...read the label three times:once, before you remove the medicine from the cabinet; again,before you take it; and a third time, when you return it to themedicine chest. Never take medicine in the dark, no matter howsure you think you are of its location. Keep the label up whenpouring liquid medication, so that the instructions do not becomeobscured by drippage.

Version B: Medication Guide: How to take your medication properly1. TAKE YOUR MEDICATION. Your doctor chose the bestmedicine for you. You waste time and money if you do not followyour doctor's advice.2. FOLLOW THE INSTRUCTIONS FOR TAKING YOURMEDICATION. Your doctor carefully chose how much medicationyou should take. Your doctor also carefully decided when youshould take it. Your medication will work better if you follow theinstructions exactly. Too much medication or too little medicationcan be harmful.3. READ THE LABEL. On the label, your pharmacist printsinstructions about how you should take your medication. Then thepharmacist puts this label on your medication container. Make sureyou understand these instructions. Each time you take yourmedication, you should read the label to make sure you have thecorrect medication. Do not take your medication in the darkbecause you might take the wrong one. Keep the label facing youwhen you pour liquid medication so that it does not run down thelabel and make the instructions hard to read.


APPENDIXB

Excerpts from Comprehension Tests

Part I: Question on Medication Guide" [Free Written Test]

INSTRUCTIONS: The medication guide gave you 12 helpful hintsor instructions for taking medication correctly and safely. Write asmany of these rules as you can remember. Please write sentences.You may write the rules in any order. The first and last rules areprovided for you.1. Take your medication.2.3.

Part II: Questions on "Medication Guide" [Short Answer Test]

INSTRUCTIONS: Please fill in the blanks with information fromthe pamphlet "Medication Guide".

6. If you feel better before you finish taking all of your medicationyou should

12. You have been working in your yard all weekend, and nowyour back is sore. You talk to your brother-in-law. He tells youthat he had the same problem 2 weeks ago, and his doctor orderedsome medication that really worked! He offers it to you, since hisown back is better now. You should


effect of lowering the reading level of a health education pamphlet on increasing

Documents